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UMR Medical Plans - UHC Choice Plus Network
Refer to the Summary Plan Descripton (SPD) for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage.
IN NETWORK BENEFITS
Description of Coverage
CLASSIC
Deductible/Per Plan Year
Individual/Family
(
Embedded Deductible
*
)
$3,000/$6,000
Coinsurance Per Plan Year
30%
Maximum Out-of-Pocket/Per Plan Year - Individual/Family
(Includes deductible, copayments and coinsurance)
$6,350/$12,700
Office Visit/Specialist
$25/$50
Preventive Services
100%
Hospitalization
30% after deductible
Routine Diagnostic Lab
No Charge
X-ray (Excluding complex scans)
No Charge
Complex Diagnostic Testing MRI/CT/PET
$250
Eye Exam - Limited to one exam every 24 months
$25
Emergency Room
$250
Urgent Care
$100
PHARMACY BENEFITS
RETAIL - UP TO 30 DAY SUPPLY
MAIL ORDER - UP TO 90 DAY SUPPLY
Generic
$15
$37.50
Brand
$45.00
$112.50
Non-Preferred Brand
$85.00
$212.50
Specialty
30 day supply for $170
RATES - Medical Plans
CLASSIC
Employee per month
Employee per paycheck
Employee Only
$70.62
$35.31
Employee + Spouse/Partner
$588.49
$294.24
Employee + Child(ren)
$541.41
$270.71
Employee + Family
$1,106.38
$553.19
* Deductions based on 24 pay-periods
* An Embedded Deductible means that one person in a family can meet their individual deductible at which point the health plan will begin paying.
The remainder of the family can make up the remaining portion of the family deductible. The deductible year is January 1, 2017 - December 31, 2017.
BENEFIT DOLLARS
CPI’s current monthly Cafeteria Plan Benefit Dollar contribution is $136/month (pro rated for part-time employees). These
Benefit Dollars may be applied toward the “Cost to Employee” medical plan rates above and/or towards the purchase of
additional benefits. Unused Benefit Dollars will be forfeited. CPI benefit dollars may be used for contributions to the Flexible
Spending Account and the Health Savings Account but cannot be used for contributions to the 401(k).